The assessment and treatment of children and adolescents with sexually abusive behavior.

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The assessment and treatment of children and adolescents with sexually abusive behavior requires an understanding of normal sexual development. A multiplicity of biological and psychosocial factors determines the child's sexual development, gender role, sexual orientation, patterns of sexual arousal, sexual cognitions, sexual socialization, and the integration of sexual and aggressive patterns of behavior. The individual's sexuality evolves in concert and as a result of interaction with family, ethnic, social, and cultural influences. These parameters summarize what we know about the epidemiology and phenomenology of sexually abusive youths and provide guidelines for the assessment and the selection of treatment interventions for these youths. Essential considerations in the assessment and treatment of sexually abusive youths, as well as the different categories of sexually abusive youths which should be recognized and which influence treatment decisions, are presented. The spectrum of currently available psy chosocial and biological treatments will be summarized. J. Am. Acad. Child Adolesc. Psychiatry, 1999, 38(12 Supplement):55S--76S. Key Words: juvenile, sex, sexual abuse, sex offender, practice parameters, guidelines, children, adolescents.

There is evidence of a significant increase in the reports of juvenile sexual aggression and sexual abuse. Sexual assault is one of the fastest-growing violent crimes in the United States. Approximately 1 out of 3 women and 1 out of every 7 men will be sexually victimized before 18 years of age.

Studies of adult sex offenders have demonstrated that the majority self-report the onset of sexual offending behavior before 18 years of age. Approximately 20% of all rapes and 30% to 50% of child molestations are carried out by youths younger than 18 years of age. Studies of adolescent sex offenders have shown that the majority commit their first sexual offense before 15 years of age and not infrequently before 12 years of age. There are increasing reports of preadolescent sexual abusers.

The recognition of a group of children and adolescents who sexually abuse others requires that we begin to develop empirically based methods of assessment and intervention strategies so that the sexually abusive youths of today do not become the adult sex offenders of tomorrow.

EXECUTIVE SUMMARY

THE EVALUATION PROCESS

The evaluation and treatment of children and adolescents with sexually abusive behavior require an understanding of the biological and psychosocial factors determining the child's sexual development, gender role, sexual orientation, patterns of sexual arousal, sexual cognirions, sexual socialization, and the integration of sexual and aggressive patterns of behavior. The individual's sexuality evolves in concert and as a result of interaction with family, ethnic, social, and cultural influences.

The clinical assessment of juvenile sexual abusers requires the same comprehensive evaluation as is required for other children and adolescents. Important sources of information include medical and psychological reports, offense reports, victim statements, protective services reports, and probation reports. The collateral information should be obtained before the individual interview; otherwise one is left relatively unprepared before the offender's normal proclivity to minimize and deny.

Forensic Considerations

It is essential that the clinician define his or her role in the assessment of the sexual abuser. While many of the issues are relevant to a forensic evaluation, these parameters are designed to provide guidelines for the clinical evaluation of the sexual abuser. It is generally preferable to conduct the clinical evaluation after adjudication. The focus of the clinical interview is on assessing amenability to treatment, required levels of care, treatment goals and objectives, and the risk of reoffending. The juvenile sex abuser is advised of reporting laws and the limits of professional confidentiality. An informed consent signed by the juvenile and his or her parent/guardian should be obtained prior to the clinical interview. It is important to educate and clarify for the individual and his or her family what is going to happen and when. The role of protective services and the juvenile justice system should be explained when relevant. Consent forms should he developed to cover the use of controversial asses sment and treatment procedures such as phallometric assessment, aversive conditioning, and medications that are not accepted as standard of practice.

The Clinical Interview

The clinical interview is the cornerstone of the evaluation of juvenile sexual abusers. It is necessary to establish the nature of the sexually abusive behavior. Because in many cases laws have been transgressed, the offender is often less than forthcoming. Issues of shame, guilt, and fear of punishment impede disclosure. The clinician is advised to adopt a nonjudgmental stance and to relate to the juvenile offender in a matter-of-fact, exploratory manner. The clinician clarifies the meaning of sexual jargon and avoids its use. The interview is initiated with a nonthreatening line of questioning, thereby minimizing the initial defensiveness. The interviewer develops lines of questioning in order to learn more about the offender and the offender's family, school, and current life situation. The interviewer confronts minimization, denial, and the apparent omissions of important information. There is little value in getting angry and accusatory. It is more useful to be patient, persistent, and not easily dissuad ed.

Assessment of the Sexually Abusive Behavior

In the evaluation the clinician develops certain lines of questioning regarding the sexual abuser and the sexual abuse incident.

Sexual-Aggressive History. The clinician obtains the juvenile's sexual history and assesses the juvenile's sexual knowledge and education, sexual development, and sexual experiences. Inquiries are directed to assess the juvenile's knowledge about gender differences and sexual intercourse and the juvenile's preferred patterns of sexual behaviors. Specific questions may be asked regarding the juvenile's understanding and knowledge of normal sexual activities, i.e., kissing, dating, petting, masturbation, and whether he or she has been sexually active and engaged in intercourse or homoerotic experiences or has been exposed to inappropriate and explicit sexuality. The clinician attempts to delineate the established pattern and spectrum of previously committed sexually aggressive acts; the victim profile; the internal and external triggers that initiate the sexual abuse cycle; the role of aggression and sadism in the sexual offense; the need to dominate, control, and humiliate the victim; the erotization of the ag gression; and the history of sexual victimization, physical abuse, and emotional neglect. It is necessary to discriminate between compulsive sexual behaviors and paraphiliac compulsive sexual behaviors. Is there a history of prior nonsexual delinquent behavior or a history of arrests, convictions, incarcerations, use of weapons, or cruelty to animals?

Developmental and Psychosocial History. Other areas of the assessment process are those associated with a comprehensive developmental history, i.e., the nature of the pregnancy, perinatal history, developmental milestones, family relationships, early identificatory models, capacity for relationships, peer relationships, and social skills. The family assessment provides an opportunity to understand the early developmental and environmental context within which the sexual abuser developed. Information is obtained regarding the parents' personal and psychological history, their use of authority and discipline, and the role of coercive sexuality in the family. How is affection, tenderness, competition, aggression, love, sexuality, and lust expressed in the family? How supportive and available is the family as a treatment resource?

Medical and Psychiatric History. It is important to obtain a comprehensive medical and psychiatric history with specific attention to psychopathology, substance abuse, and psychiatric comorbidity.

School History. A specific area of concern is the evaluation of intellectual capacities and academic performance. Fifty percent to 80% of juvenile sexual abusers have learning problems, repeated a grade in school, and/or have been in classes for the learning-disabled.

Mental Status Examination. A comprehensive mental status examination is carried our to assess the presence of psychopathology, personality disturbances, organicity, and substance abuse and to acquire an understanding of adaptive, coping, and defensive strategies. Suicidal content and risk should be assessed specifically. A careful assessment of the spectrum of suicidal behavior is undertaken to establish the degree to which suicidal ideation and history of suicidal behaviors, threats, or plans are present. Apprehension by judicial authority and the associated shame of exposure, embarrassment, stigmatization, and fear of punishment and incarceration are risk factors for suicidal behavior.

Psychological Tests

There are no specific empirical measures or psychometric tests that can identify, diagnose, or classify sexual abusers, although psychological testing may be used adjunctively to understand the personality traits, sexual behaviors, and intellectual capacities of these youngsters.

Phallometric Assessment

Some authors have recommended the use of phallometric testing, the measuring of penile erection in response to various stimuli, as a way to determine sexual preferences. This technique is usually reserved for the most severe and older juvenile sexual abusers. This procedure has generally been used with caution because of the lack of empirical studies, problems in obtaining informed consent, and a reluctance to expose children and adolescents to further sexual stimulation through the portrayal of deviant sexual activities.

Disposition

At the end of the assessment process, the clinician should be prepared to address the following issues and to provide guidance to other professionals, the juvenile court, and community agencies:

* The risk of repeating the sexually aggressive behavior.

* The treatment needs of the individual and the individual's family.

* The appropriateness of removing the sexual abuser from the family.

* The appropriate treatment program for the abuser, e.g., a community outpatient treatment program or a more restrictive environment, such as a detention center, residential program, or inpatient unit.

In the final stages of the evaluation, it is useful to discuss the possible treatment alternatives with the patient and appropriate family members and to explain to the family members what their participation in the treatment program will be.

TREATMENT

The spectrum of emotional, behavioral, and developmental problems presented by these young people requires an integrated, multimodal treatment program which is tailored to the individual's clinical presentation and social and family support system. The treatment of juvenile sexual abusers has generally focused on several objectives, which are integral to a successful intervention:

* Confronting the sex abuser's denial.

* Decreasing deviant sexual arousal.

* Facilitating the development of nondeviant sexual interests.

* Promoting victim empathy.

* Enhancing social and interpersonal skills.

* Assisting with values clarification.

* Clarifying cognitive distortions.

* Teaching the juvenile to recognize the internal and external antecedents of sexual offending behavior with appropriate intervention strategies.

The predominant treatment approaches include cognitive-behavioral and psychosocial therapies and psychopharmacological interventions. A group setting is the preferred format in treatment programs for sexual abusers and is usually the conduit through which cognitive-behavioral modalities (such as psychoeducational, behavioral, and relapse prevention programs) are conducted.

Cognitive-Behavioral Interventions

Psychoeducational modules provide information about sexuality, sexual deviancy, cognitive distortions, interpersonal and social behaviors, and strategies for coping with aggressive and sexual impulses. Specific educational modules may include victim awareness/empathy, cognitive restructuring, anger management, assertiveness training, social skills training, sexual education, stress reduction and relaxation management, and autobiographical awareness. Specific behavioral techniques that have been used to diminish deviant sexual arousal include covert sensitization, assisted covert sensitization, imaginal desensitization, olfactory conditioning, satiation techniques, and sexual arousal reconditioning.

Relapse prevention assumes that sexual offenses are the product of contextual triggers and an array of emotional and cognitive precursors. In this intervention, the sexual abuser becomes aware of each phase of his or her sexual assault cycle and its unique characteristics in order to become knowledgeable about the triggers that initiate the cycle. The goals of relapse prevention are to empower offenders to manage their own sexual life through a cognitive understanding of the antecedents of their sexual offending behavior and the development of coping strategies with which to interrupt the sexual offending cycle.

Psychosocial Therapies

Psychosocial therapies include traditional individual approaches, family therapy, group therapies, and the use of the therapeutic community.

Group therapy with juvenile sex offenders provides a context in which the sexual abuser is unable to easily minimize, deny, or rationalize his or her sexual behaviors. Peer group therapy, as the medium for therapeutic interventions, is used in a number of different ways depending on the setting, group membership, severity of the sexual offenses, group goals and objectives, whether the groups are open or closed, and the length of the group experience. Therapeutic community groups are often used in hospital or residential treatment settings as a vehicle for milieu administrative decision-making and for the monitoring of a behavioral management system.

Family therapy may be most useful in those instances in which there is incest, especially when the sex offender remains in the family or will rejoin the nuclear family after treatment. Family therapy facilitates the learning of new ways of communicating and building a support system which will help interrupt the abuse cycle and ultimately be supportive to the offender's capacity for regulating and modulating aggressive sexual behavior. The parents should be seen for counseling or be placed in a concurrent structured parent group with an emphasis on educational modules where they can become familiar with sexually abusive behavior, risk and protective factors, characteristics of sexual abusers, treatment strategies, and most importantly focus on styles of interaction and management of their children's sexual behavior.

Individual therapy is usually used in conjunction with other treatment approaches and probably should never be relied on as the only treatment modality. However, individual therapy may be the treatment of choice for the younger, sexually reactive abused child who has become sexually abusive. This is particularly true for children who manifest high levels of intrapsychic conflict, emotional distress, confusion, and defensiveness around their own sexual victimization.

Psychopharmacological Interventions

Selective serotonin reuptake inhibitors (SSRIs) have been shown to have an impact on sexual drive, arousal, and sexual preoccupations. Fluoxetine has been the agent most studied, and there are a number of reports indicating that its use is associated with a reduction in paraphiliac behavior and nonparaphiliac sexual obsessions.

The antiandrogen drugs are reserved for the most severe sexual abusers and are generally discouraged for use in adolescents younger than 17 years of age. Antiandrogen medications should never be used as an exclusive treatment for paraphiliac and aggressive sexual behaviors.

LITERATURE REVIEW

A computer literature search based on Medline and Psychological Abstracts using key words such as child, adolescent, juvenile, sex, sexual, abuse, abuser, offenses, and offender was obtained. References included major review articles, book chapters, and monographs as well as journals with a specific focus on sexually abusive behaviors. In addition, the authors and consultants contributed from their own cumulative clinical and professional experiences.

DEFINITIONS

Sexually abusive behavior occurs without consent, without equality, or as a result of coercion (National Task Force on Juvenile Sexual Offending, 1993). In this context consent is defined as including all of the following: (1) understanding what is proposed, (2) knowledge of societal standards for what is proposed, (3) awareness of potential consequences and alternatives, (4) assumption that agreement or disagreement will be respected equally, (5) voluntary decision, and (6) mental competence. Equality is defined as "two participants operating with the same level of power in a relationship, neither being controlled or coerced by the other." Coercion is defined as "exploitation of authority, use of bribes, threats of force, or intimidation to gain cooperation or compliance" (National Task Force on Juvenile Sexual Offending, 1993, p. 9). The commonly used terms in the sexual abuse literature and their definitions are noted in Table 1.

NORMAL SEXUAL DEVELOPMENT

The developing child learns about sexuality, internalizes sexual values, and enacts various sexual roles as a result of exposure to familial, societal, and cultural experiences. Traditionally, society has placed restraining influences on childhood sexuality. There has been a tendency to avoid sexual stimulation, to inhibit sexual impulses, to prohibit erotic play, and to reduce or forbid sexual self-stimulation (Rosenfeld and Wasserman, 1993). A majority of children, however, will engage in some manifest sexual behaviors and sexual activities with others before 13 years of age (Araji, 1997; Friedrich et al., 1991; Johnson, 1999). The sexual life of children begins to configure shortly after birth and becomes patterned upon the bases of early sensitizing experiences. In the first year of life, most children discover the pleasure of genital self-stimulation. By 3 to 4 years of age, children may begin to engage in sexual play with peers. Penile erections, thigh rubbing in female preschoolers, sexual exploration games, touching and rubbing of one's genitals, exhibitionism, voyeurism, use of "dirty" language, and flirtatious behaviors have been described in normal children 2 to 6 years of age (Araji, 1997; Friedrich et al., 1991). Sexual interests during the middle childhood years wax and wane with the degree of sexual stimulation and sexually sensitizing experiences. Kissing and holding hands may occur. Sexual play between children such as "playing doctor" is normal and becomes a concern only when coercion occurs and there is an absence of mutual consent. In the process of growing up, children are invariably sexually stimulated and sometimes sexually aroused. They continually seek sexual information and greater understanding about the nature of sexual life. Through play and sexual exploration with others, as well as through gender-role enactments, the child begins to assimilate the elements of sexual life and establish patterns of sexual excitement and pathways to sexual gratification. Most sexual play is between ch ildren who have an ongoing mutually enjoyable play relationship and/or school friendship. The child's interest in sex and sexuality is balanced by curiosity about other aspects of his or her life. Sexual behaviors of children vary greatly and are influenced by fortuitous and opportunistic experiences, the degree of sexual stimulation, the child's sexual interest and curiosity, as well as previous sexual experiences (Johnson, 1999). Normative sexual play is usually spontaneous and includes pleasure, joy, laughter, embarrassment, and varying levels of inhibition and disinhibition (Araji, 1997). Masturbatory behavior becomes more frequent in preadolescence. Masturbation is considered excessive when the child's masturbatory practice leads to pain or bruising or occurs in public.

Money (1986) suggested that a relatively stable and preferred pattern of sexual gratification and erotic imagery can occur as early as 8 years of age. He introduced the concept of the "lovemap." The lovemap is conceptualized as a developmental representation in the mind. It is a schema depicting the preferred sexual object and the preferred sexual-erotic behavior which evolves out of the developmental experience with others.

While early development provides the crucible for the development of sexual values, it is apparent that sexual development is greatly facilitated during the middle school years when children are increasingly exposed to the popular culture (Postman, 1994). In contemporary society children and adults have virtually equal access to sexually explicit information vis-a-vis videotapes, the Internet, television programming, and pornographic magazines. The age of "electronic information" has resulted in the popular culture in many instances superseding the family as the source of information about what is acceptable sexual behavior (Postman, 1994).

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EPIDEMIOLOGY

Acts of sexual aggression have become increasingly commonplace. There has been an increase in both violent crimes committed by juveniles (Office of Juvenile Justice and Delinquency Prevention, 1994a) and in the reports of sexual aggression and sexual abuse (Hampton, 1995). The National Committee to Prevent Child Abuse (1998) estimates that of the 1 million cases of confirmed child maltreatment in 1997, approximately 8% were the victims of sexual abuse. Sexual assault is one of the fastest-growing violent crimes in the United States and accounts for 7% of all violent crimes (Hampton, 1995).

While adolescents (15-18 years) make up only ...

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